Antenatal, perinatal, and primordial cardiovascular prevention: What is known, what is happening, and future directions

Although there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of mortality and morbidity globally.1 Primary and secondary prevention in adults represent milestones in order to improve the health status of a population.2 An increasing number of cardiovascular health factors have been associated with the prevalence and incidence of several diseases: ASCVD events, heart failure, atrial fibrillation, cancers, depression, and cognitive impairment.2 Therefore, moving individuals toward ideal cardiovascular health is important for the prevention of many important health conditions. Few information is available and there is low attention regard primordial cardiovascular prevention, as well as prevention in the antenatal and perinatal periods. The paper by D’Ascenzi et al. focuses on these very important topics, providing a complete review of the contributions available in the field.3 In this commentary, starting with the paper by D’Ascenzi et al.,3 after a summary of the available knowledge in this area, an analysis of the gap between what we are doing and what we should do will be provided. An increasing number of chronic diseases have been observed, especially metabolic disorders such as diabetes mellitus and obesity, as having a very important role in ASCVD risk.4 This phenomenon does not only involve adults and the elderly, but, day by day, it is also playing a major role among adolescents and young adults.3,5 It is important to stress that ASCVD factors are able to negatively impact each stage in life. Correctly, D’Ascenzi et al. state that ASCVD prevention should start as soon as possible.3 The American Heart Association defined a new model of “ideal cardiovascular health” based on seven health metrics, for both children and adults, referred as “Life’s Simple 7”6: four healthy behavioural items, such as non-smoking, having a normal body mass index, being physically active, and healthy eating; and three health factors, including blood pressure, cholesterol, and plasma glucose level. It has been reported that reducing the number of these metrics during childhood and adolescence reduces the incidence of arterial hypertension, metabolic syndrome, and dyslipidaemia; moreover, an inverse correlation exists between the number of metrics and carotid intima media thickness and arterial stiffness.7,8 The individual ASCVD risk profile is influenced by the genetic patrimony, which cannot be directly manipulated.3 Nevertheless, D’Ascenzi et al. correctly state that healthy behaviour in the family is very important also in this field, since a tight relation between genetics and environment exists, with a reciprocal influence.3 Evidence is available8–10: dietary counselling, sodium restriction, and physical activity in children have beneficial effects on plasma lipid profile, blood pressure levels, and abdominal fat; also, insulin sensitivity and arterial stiffness are improved. Sharing these favourable effects with parents, with a virtuous diffusion of a healthy lifestyle, is a specific feature of family-based interventions. Nutrition and physical activity are also milestones in these stages of the life; in their review, D’Ascenzi et al. underline some interesting data regarding their beneficial effects on endothelial function and retinal microcirculation.3 Concerning the intrauterine life, pregnancy-related hypertensive disorders might significantly influence the ASCVD risk profile of the offspring3; moreover, intrauterine exposure to a diabetic environment may have an impact on biventricular geometry and function later in the life. An appropriate method of management of these pregnancy-related disorders may play a relevant role as a preventive measure.3 Finally, the increasing number of preterm births represents an epidemiologically relevant issue, involving around 15 million babies each year, worldwide.3 Preterms present a typical cardiac remodelling: left ventricular mass is increased, both ventricles show a reduced volume, and a reduced apical displacement is present.3 Left ventricular ejection fraction is preserved during rest, but a reduction during exercise has been demonstrated.3 A possible association between the risk of developing heart failure in young adults and the degree of prematurity has been hypothesized.3 In preterms, an association with a higher risk of future systemic hypertension and stroke exists, as compared to full-term newborns; this risk is independent from the cardiac alterations3 – increased arterial stiffness, reduced cutaneous capillary density, and endothelial function may play a role as drivers of this unfavourable evolution.3 However, these pathophysiological substrates are not entirely understood and future studies are needed to investigate the impact of negative cardiac remodelling observed in preterms on the future ASCVD risk profile. After an alarming rise in mortality from ASCVD in the 1950s in most industrialized countries, the ASCVD epidemic levelled off and an impressive decline started. That decline has occurred in most European countries, commencing earlier in some compared to others.11 However, the epidemic is still very dynamic in different parts of the world and changes may again occur in the wrong direction. There is clear evidence that traditional ASCVD risk factors, including elevated blood pressure, blood cholesterol, and blood glucose, have their origins in childhood and adolescence. Nevertheless, there is low cardiovascular disease awareness among young people. In a recent paper, Gooding et al.12 assessed awareness of ASCVD and prevention efforts among 331 young women aged 15 to 24 years from the American Heart Association National Women’s Health Study survey. Responses from this cohort were compared to the 2012 American Heart Association online survey of 1227 women aged 25 years and older. The results are rather disturbing: only 10% of the young women correctly identified ASCVD as the leading cause of death in women, a proportion which is significantly lower than that found among all adult women in 2012 (64.0%) and women aged 25 to 34 years (53.6%) (P < 0.01 for both).12 Many (43.5%) young women said they were not at all informed about ASCVD; most worried little (39.2%) or not at all (38%) about ASCVD.12 Therefore, the most important barrier to engaging in prevention behaviours is the lack of knowledge about the “killing power” of ASCVD, and, as a consequence, not considering oneself at risk. As D’Ascenzi et al. correctly underline, the current situation in Europe regarding the adoption of proper measures for a healthy lifestyle is also unfavourable.3 Considering healthy eating and physical exercise, compliance to the current recommendations varies considerably according to gender and country: from 2% in Cyprus to 14.7% in Sweden for girls, from 9.5% in Italy to 34.1% in Belgium for boys.3 Paradoxically, a low adherence to the Mediterranean diet among children living in Mediterranean countries has been demonstrated.3 More should be invested in the earliest possible prevention of ASCVD from childhood onwards. This can be achieved by aiming for a non-smoking generation of adolescents who keep physically active throughout life, preventing the development of overweight and obesity. The authors correctly stress that medical doctors, nurses, scientific communities, and politicians should promote the most appropriate preventive measures since the youngest ages.3 Since ASCVD risk factors begin to accumulate risk early in life, the promotion of cardiovascular health and heart disease awareness among young people is essential to reduce the burden of ASCVD worldwide. Future studies should explore effective strategies for linking heart health promotion with issues that matter to young people, as well as health communication channels most likely to reach childhood and adolescents. These strategies should also involve the whole family and not only the child, in order to be beneficial for all members of the family. Finally, as the authors correctly underline, ante- and perinatal ASCVD prevention is still developing, with few data available.3 Thus, more research is needed to better study the role of ASCVD prevention during pregnancy and in premature babies. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.